1. In-Custody Interventions and Diversion for People with Mental Illness A New Service Delivery System that Works NAMI North Carolina Decriminalization Conference Raleigh, NC November 27, 2007 Connie Milligan and Ray Sabbatine Bluegrass Regional MH-MR Board

2. Review of the Problem Jails are the new psychiatric institutes  Closing of hosp beds in the 60’s - current  Limited funding for community mental health resources  80’s War on drugs - Get tough on crime  8%-16% of 11m bookings have MI – Bureau of Justice Statistics - 2000  73% F and 63% M incarcerated have HX of MI – Bureau of Justice self report 2002  64% of people in local jails have some MH symptoms Bureau of Justice Statistics Special Report. September 2006  70% incarcerated have co-occurring disorders  Inmate with MI jailed 2-3 times longer  Suicide rate in jail is 9 times higher – now 4% higher – Lindsay Hays web site: /www.ncianet.org

3. Community Response Trends  CIT provides first point of diversion  Judges see the revolving door person with MH- SA problems  Courts initiate “problem solving courts”  Judges and probation officers take on leveraging role for TX  MH initiate new TX models with ACT  Community Mental Health remains under funded  Jails still have legal responsibility to respond with limited resources

4. KY Model of Partnership… Handshake between Jails and Mental Health People with mental illness filling KY jails – suicide rate high CJ report in ‘02 Mandated training for jail staff Jails still wanted services Developed Telephonic Triage Success of pilot in ’03 prompted legislative lobbying Legislation passed ‘04 Implementation began Fall ‘04

6. Jail Mental Health Crisis Network Identify Intake Assessment Booking Screening Institutional Alert Observation Request Telephonic Triage Charge Shame Substance Abuse Suicide Mental Illness Mental Retardation Acquired Brain Injury Risk Assessment Critical High Moderate Low Follow-up Referral Crisis Counseling Diversion 202A 504 Psychiatrist Hospital TriageLevelRespond

7. Jail Mental Health Interfaces Jail Intake Assessment Institutional Alerts/Observation Booking Screening Secondary MH Assessment Protocol Management MH Consultation Management MH Release Planning

8. Assessment Need: MedicalMedical Mental healthMental health SuicideSuicide Risk related to the chargeRisk related to the charge Police Screening Instrument

9. Assessment MedicalMedical Mental healthMental health SuicideSuicide Substance abuseSubstance abuse ABIABI MRMR Risk related to chargeRisk related to charge Component: Booking Screening

10. Jail Initiating the Telephonic Triage

11. The Mental Health Assessment Tool Data Dictionary Training Instrument

12. The Type of charge Risk Related to the Charge Misdemeanor, Felony or Capital Offense Yes or No? Public Embarrassment Life Altering Event Critical, High, Moderate or Low

13. Suicide Risk Levels

14. Behavior Health Triage Suicide Risk Levels Assessment of suicide risk The clinicians best judgment of the likelihood that arrestee will make an attempt to take his/her life while incarcerated Critical  Arrestee needs critical level of risk containment to reduce high risk behavior as evidenced by: Arrestee has immediate and clear intent to take his/her life as demonstrated by a current attempt with self harming/life threatening behavior

15. Behavior Health Triage Suicide Risk Levels  Arrestee needs high risk containment measures to reduce risk as evidenced by any one of the following: History of attempt in jail Current suicidal ideations History of attempt within last two years Attempt required medical attention High degree of shame related to charge · Any of these factors can be confounded by the presence of substance toxicity HIGH

16. Behavior Health Triage Suicide Risk Levels  Arrestee needs moderate risk level containment to monitor suicidal risk as evidenced by: History of prior attempt more than two years Suicide survivor Moderate

17. Behavior Health Triage Suicide Risk Levels Arrestee needs low risk level containment to monitor suicidal risk as evidenced by: –No history of suicide in the family –No current attempts –No current ideations for self harm –No history of attempts in the last ten years LOW

18. Substance UsePotential for withdrawal Yes or No Describe Refer to Medical

19. Drug Withdrawal Symptoms  ALCOHOL – 2-3 days, up to 2 wks after last use  Severe withdrawal = DT, AV hallucinations, seizures, vomiting & diarrhea, depression  BENZODIAZEPINES - 12-24 hours after last use  Severe withdrawal = Depression, suicidal ideation, agoraphobia, seizure –  OPIATES - 8 hours after last use  Moderate withdrawal = Sweating, running nose, eyes’ yarning & restlessness, stomach cramps, dilated pupils and joint pain  Severe – can be fatal  AMPHETAMINES  Severe withdrawal = Psychosis, suicidal ideation, existential crisis  COCAINE  Moderate withdrawal = Anxiety, agitation, depression, extended sloop and fatigue, appetite increase  Severe – Increased hostility – High risk for Suicide

20. Depression

21. Mania

22. Personality Disorders

23. Other Risk Factors Homicidal Ideations History of victimization/ trauma/ Post Traumatic Stress Disorder (PTSD) History of substance abuse

24. Hospitalization and Treatment Name of TX Provider HX of Hospitalizations Current Medications

25. Leveling Process Charge Related Risk Substance Abuse Suicide Risk Depression Mania Psychosis Personality Disorder Risk Assessment Levels Critical High Moderate Low Mental Health Symptoms MR/ABI/ SA

26. CRITICAL RISK  Arrestee needs critical level of risk containment to reduce high risk behavior as evidenced by: Immediate and clear intent to take his/her life as demonstrated by a current attempt of life threatening harm toward self or others

27. CRITICAL Risk Protocols Housing Restraint (Chair) Supervision Clothing Property Food Constant Observation 2/4 Policy Regular Jump Suit None Finger food

28. HIGH RISK  High – Arrestee needs high risk containment measures to reduce risk as evidenced by any of the following: Designation of HIGH suicide risk behavioral health symptoms in any one or more of the categories that pose a risk of harm to self or others

29. High Risk Protocols Housing Safe Cell / Single if Violent Supervision Clothing Property Food Frequent and Staggered Suicide Smock None/Suicide Blanket Finger food

30. MODERATE RISK  Arrestee needs moderate risk level containment to monitor risk as evidenced by any of the following: Designation of MODERATE suicide risk Behavioral health symptoms in any one of the categories that pose a minimal risk to self or others

31. Moderate Risk Protocols Housing As Classified Supervision Clothing Property Food Individualized Checks Regular Jump Suit Full Regular

32. LOW RISK  Arrestee has low risk when Designation of LOW suicide risk No significant behavioral health symptoms

33. Low Risk Protocols Housing As Classified Supervision Clothing Property Food As Classified Regular Jump Suit As Classified Regular food

34. Sharing Information HIPPA – not a problem

35. Data Exchange  Triage form emailed or faxed to the jail and the local CMHC  For email: “Adobe Reader” displays form  Form becomes part of the inmate’s file  CMHC response also added to the file  Data from the form is reported by categories of risk  Data substantiates jail’s needs  Data facilitates outcome evaluation

36. Follow Up CMHC Services  Local CMHC called for all acute cases  Definition of Consultation defined  Evaluation  Crisis Counseling  Assess need for hospitalization, medication, diversion  Response times are tied to level of risk  Critical – 3 hours  High – 12 hours  Moderate – Next business day or as needed

37. Response Process Local clinician reassesses situation Go through the flags & triage details Interview arrestee Clinician in role of advocate for the inmates safety and humane treatment Increase diversion opportunities Identification of risk Assessment of risk Leveling of risk Management of risk Prevention of risk

38. Response Process Is risk level still appropriate? Are management protocols appropriate? Issues to consider : –Current mental health status –Substance intoxication/withdrawal –Risk related to suicide –History of TX, prior jail behavior Is there need for diversion to higher level of care? Identification of risk Assessment of risk Leveling of risk Management of risk Prevention of risk

39. Response Process Give recommendation: Management issues to consider – –Duration of incarceration –Immediacy of treatment needs –Cause of behavior problems –Ability of jail to appropriately respond to needs Identification of risk Assessment of risk Leveling of risk Management of risk Prevention of risk

40. Response Process Diversion Can charges be dropped? Give DC info for care if bonding out Identification of risk Assessment of risk Leveling of risk Management of risk Prevention of risk

41. KJCN Program Summary  90% jail participation  80% reduction in-custody suicide  Screening instruments are working  Triaging 5-15% of bookings  Protocols provide consistency  Cross training of jail and CMHC staff  Follow-up provides immediate MH expertise  Diversion is increased  Collaboration/interface with pretrial release services, courts, forensic hospitals and substance abuse diversion  New developments – video conferencing for MH services

42. Triage Program Data Summary  Total Triages since 9-1-04 = over 28,000  Charges:  63% Misdemeanors  36% Felonies .06% Capitol Offenses  Charge a risk factor = 11-14%  Hospitalization in last six months = 36% Suicide critical or high risk in 35%  Any suicide risk 65%

43. Triage Program Data Summary  Substance Abuse risk = 36%  Withdrawal risk present = 19%  Mental Health Risk = 75% with symptoms  Depression 43%  Mania 23%  Psychosis 8%  Personality DO 40%  Summary of Mental Health Risk Level Critical = 2%Critical = 2% High = 37%High = 37% Moderate = 46%Moderate = 46% Low = 15%Low = 15%

44. Triage Program Data Summary  Follow Up Referral  46% of all Triages have follow up referrals  12% meet civil commitment criteria  1% meet competency evaluation criteria  Response Time Compliancy  Overall response 98%

45. Triage Program Data Summary  Follow Up Referral  45% of all Triages have follow up referrals  13% meet civil commitment criteria  1% meet competency evaluation criteria  Response Time Compliancy  Overall response 98%

46. For More Information Connie Milligan 859-253-1686 x 570 cpmilligan@bluegrass.org Ray Sabbatine 859-806-0935 sabbatine@adelphia.net Articles  Behavioral Healthcare – August 2006 http://behavioral.net/issues/2006/08/027/  Corrections Today – February 2006 http://www.aca.org/fileupload/177prasannak/Milligan web.pdf